Referral Form

DV Therapy provides speech, occupational, behavioral health, and mental health services in and around the areas of Antelope Valley, Bakersfield, Los Angeles and San Gabriel Valley.

If you are seeking an evaluation and/or services with DV Therapy Inc., please fill out the attached form.

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Email *
Clinical location
*
Client's Name *
Date of Birth
*
Full Address
*
Zip Code
*
Parent's Name (If applicable)
*
Cell Phone
Email
*
Doctor's Name
*
Preferred Method of Communication?
*
Is this evaluation for speech, occupational therapy or behavioral and mental health services?
*
Required
Do you have an active referral for therapy services?
*
Have you had a Speech & Language, Occupational Therapy or Behavioral and Mental Health evaluation within the past 6 months?
*
Primary Insurance Carrier
*
Insurance ID#
Insurance Card Upload (front and back of card)
Do you have a secondary insurance?  *
Required
If yes, please provide secondary insurance carrier.
Secondary insurance ID #
Secondary Insurance Card - front and back
Requested Setting
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Medical Diagnosis (Please list any related diagnosis)
Reason for Speech Therapy Request (if applicable):
Clear selection
Reason for Occupational Therapy Request (if applicable):
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Comments (Please Provide Specific Examples to Support Request) 
*
Availability
A Super-Bill can be provided upon request for insurance reimbursement. Will this be necessary?
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How did you hear about DV Therapy?
*ANY CHANGES TO THE ABOVE INFORMATION NEEDS TO BE COMMUNICATED TO OUR BILLING DEPARTMENT. FAILURE TO DO SO MAY RESULT IN A GAP IN SERVICE. THE FAMILY IS FINANCIALLY RESPONSIBLE FOR ALL SERVICES NOT COVERED BY INSURANCE* 
HIPAA
*
Required
Today's Date *
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